Oxygen Fires in Healthcare Facilities

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Nickolas George
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1 Oxygen Fires in Healthcare Facilities Mike Ralph Director of Estates Croydon University Hospital Workshop 2012 Oxygen Safety 1

2 Contents Introduction What can happen when it goes wrong Typical timelines for an incident Lessons learnt from incidents Risk Assessment and Training Conclusions Workshop 2012 Oxygen Safety 2

3 Introduction Medical Oxygen is an essential for patient therapy in every hospital but: It introduces an element of risk into the hospital environment The risk of a fire is significantly higher when oxygen is present Oxygen is perfectly safe when used correctly Oxygen training for doctors and nurses in the correct procedures is the key to safety But.. Workshop 2012 Oxygen Safety 3

4 What happens when it goes wrong This incident occurred at in Central London on the 29 th September 2008 it started at in the morning in a four bed intensive care ward in the Cardiac Wing Paediatric patients were being treated in this area with Berlin Heart machines where a lot of oxygen is used It was all over in a matter of minutes and fortunately no patients were involved or hurt Workshop 2012 Oxygen Safety 4

5 What happened? Some interesting pictures Workshop 2012 Oxygen Safety 5

6 Can you see what is wrong with these Fire Doors? Workshop 2012 Oxygen Safety 6

7 A cylinder typical of the one involved in the incident Workshop 2012 Oxygen Safety 7

8 What the cylinder looked like after the incident Workshop 2012 Oxygen Safety 8

9 What the cylinder looked like after the incident Workshop 2012 Oxygen Safety 9

10 What the cylinder looked like after the incident Workshop 2012 Oxygen Safety 10

11 What the cylinder looked like after the incident Workshop 2012 Oxygen Safety 11

12 What the hospital ward looked like after the incident Workshop 2012 Oxygen Safety 12

13 What the hospital ward looked like after the incident Workshop 2012 Oxygen Safety 13

14 With debris and shards of glass being projected over 10 metres Workshop 2012 Oxygen Safety 14

15 What the hospital ward looked like after the incident Workshop 2012 Oxygen Safety 15

16 The effect on the adjacent wards Workshop 2012 Oxygen Safety 16

17 What the hospital ward looked like after the incident Workshop 2012 Oxygen Safety 17

18 How far the wall moved after the explosion - almost a metre Workshop 2012 Oxygen Safety 18

19 How far the wall moved after the explosion - and from the other side Workshop 2012 Oxygen Safety 19

20 The Incident Timelines Cleaner reported being in room and noticing a burning plastic smell Ionisation Fire Detector activated in Ward Heavy smoke detected Patients immediately evacuated from ward Fire team arrive and call Fire Brigade Evacuation of adjacent areas begins Fire brigade arrives Cylinder explosion in ward - after 10 minutes Fire extinguished and area made secure Workshop 2012 Oxygen Safety 20

21 Incident Investigation Television over bed had been left on in ward believed to be electrical fault that started incident Cylinders bought in by patients left in pushchairs No controls of number of cylinders in ward Large quantities of pipeline oxygen used with medical devices in the ward poorly controlled Soft toys and combustible material present in area where oxygen was used Potential oxygen enrichment of soft materials Once started, oxygen enriched materials would burn quickly With proximity to patients, cylinders easily involved Workshop 2012 Oxygen Safety 21

22 Incident Investigation Fire believed to have started with electrical fault in television No clear evidence that oxygen supplied to adjacent medical device had been turned off Bedding and toys on bed under television had likely to have been in an oxygen enriched condition Toys caught fire and burned extremely quickly Cylinder in vicinity of fire became very hot quickly Failure of cylinder shell leading to massive explosion and releasing large amount of oxygen into fire Whole incident took only ten minutes before cylinder exploded Workshop 2012 Oxygen Safety 22

23 Lessons Learnt Oxygen Safety Carry out Risk Assessments to address oxygen safety Provide oxygen training to all staff - covering how to use oxygen safely and minimise oxygen enrichment Describe the potential risks with oxygen and fires and need to keep areas clean and tidy Ensure equipment is used correctly and critical steps logged regularly Turn off the oxygen when not in use Always use pipeline supplies to minimise cylinders on ward Control the number of cylinders on the ward - especially those brought in by patients Workshop 2012 Oxygen Safety 23

24 Lessons Learnt Fire Safety Ensure everyone fire training is up to date Provide training to staff about the potential risks with oxygen and fires Keep fire doors closed Report anything suspicious Make sure electrical equipment not in use is switched off Workshop 2012 Oxygen Safety 24

25 Conclusions What are the important issues when using assessing how to use oxygen safely in hospitals Rate at which things burn in an oxygen environment Potential for high oxygen levels in the ward areas Oxygen enrichment of clothing / soft materials Amount of energy stored in cylinders Control of number of cylinders in ward areas Control the use of oxygen turn it off when not in use Control of unnecessary combustible material Ensuring everyone is aware of the potential risks Workshop 2012 Oxygen Safety 25

26 Thank You Workshop 2012 Oxygen Safety 26

Information about oxygen

Information about oxygen INFORMATION FOR PATIENTS, CARERS AND FAMILIES 1 Why have I been given oxygen? Oxygen is vital for our bodies and having low oxygen levels can make you feel very unwell. There are